In Therapy Forever? Enough Already

By JONATHAN ALPERT

Published: April 21, 2012
The New York Times Sunday Review

MY therapist called me the wrong name. I poured out my heart; my doctor looked at his watch. My psychiatrist told me I had to keep seeing him or I would be lost.

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New patients tell me things like this all the time. And they tell me how former therapists sat, listened, nodded and offered little or no advice, for weeks, months, sometimes years. A patient recently told me that, after seeing her therapist for several years, she asked if he had any advice for her. The therapist said, “See you next week.”

When I started practicing as a therapist 15 years ago, I thought complaints like this were anomalous. But I have come to a sobering conclusion over the years: ineffective therapy is disturbingly common.

Talk to friends, keep your ears open at a cafe, or read discussion boards online about length of time in therapy. I bet you’ll find many people who have remained in therapy long beyond the time they thought it would take to solve their problems. According to a 2010 study published in the American Journal of Psychiatry, 42 percent of people in psychotherapy use 3 to 10 visits for treatment, while 1 in 9 have more than 20 sessions.

For this 11 percent, therapy can become a dead-end relationship. Research shows that, in many cases, the longer therapy lasts the less likely it is to be effective. Still, therapists are often reluctant to admit defeat.

A 2001 study published in the Journal of Counseling Psychology found that patients improved most dramatically between their seventh and tenth sessions. Another study, published in 2006 in the Journal of Consulting and Clinical Psychology, looked at nearly 2,000 people who underwent counseling for 1 to 12 sessions and found that while 88 percent improved after one session, the rate fell to 62 percent after 12. Yet, according to research conducted at the University of Pennsylvania, therapists who practice more traditional psychotherapy treat patients for an average of 22 sessions before concluding that progress isn’t being made. Just 12 percent of those therapists choose to refer their stagnant patients to another practitioner. The bottom line: Even though extended therapy is not always beneficial, many therapists persist in leading patients on an open-ended, potentially endless, therapeutic course.

Proponents of long-term therapy have argued that severe psychological disorders require years to manage. That may be true, but it’s also true that many therapy patients don’t suffer severe disorders. Anxiety and depression are the top predicaments for which patients seek mental health treatment; schizophrenia is at the bottom of the list.

In my experience, most people seek therapeutic help for discrete, treatable issues: they are stuck in unfulfilling jobs or relationships, they can’t reach their goals, are fearful of change and depressed as a result. It doesn’t take years of therapy to get to the bottom of those kinds of problems. For some of my patients, it doesn’t even take a whole session.

Therapy can — and should — focus on goals and outcomes, and people should be able to graduate from it. In my practice, the people who spent years in therapy before coming to me were able to face their fears, calm their anxieties and reach life goals quickly — often within weeks.

Why? I believe it’s a matter of approach. Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans. They don’t need to talk endlessly about how they feel or about childhood memories. A recent study by the National Institute for Health and Welfare in Finland found that “active, engaging and extroverted therapists” helped patients more quickly in the short term than “cautious, nonintrusive therapists.”

This approach may not be right for every patient, but the results described in the Finnish study are consistent with my experience.

If a patient comes to me and tells me she’s been unhappy with her boyfriend for the past year, I don’t ask, as some might, “How do you feel about that?” I already know how she feels about that. She just told me. She’s unhappy. When she asks me what I think she should do, I don’t respond with a return interrogatory, “What do you think you should do?” If she knew, she wouldn’t ask me for my thoughts.

Instead I ask what might be missing from her relationship and sketch out possible ways to fill in relationship gaps or, perhaps, to end it in a healthy way. Rather than dwell on the past and hash out stories from childhood, I encourage patients to find the courage to confront an adversary, take risks and embrace change. My aim is to give patients the skills needed to confront their fear of change, rather than to nod my head and ask how they feel.

In graduate school, my classmates and I were taught to serve as guides, whose job it is to help patients reach their own conclusions. This may work, but it can take a long time. I don’t think patients want to take years to feel better. They want to do it in weeks or months.

Popular misconceptions reinforce the belief that therapy is about resting on a couch and talking about one’s problems. So that’s what patients often do. And just as often this leads to codependence. The therapist, of course, depends on the patient for money, and the patient depends on the therapist for emotional support. And, for many therapy patients, it is satisfying just to have someone listen, and they leave sessions feeling better.

But there’s a difference between feeling good and changing your life. Feeling accepted and validated by your therapist doesn’t push you to reach your goals. To the contrary, it might even encourage you to stay mired in dysfunction. Therapy sessions can work like spa appointments: they can be relaxing but don’t necessarily help solve problems. More than an oasis of kindness or a cozy hour of validation and acceptance, most patients need smart strategies to help them achieve realistic goals.

I’m not against therapy. After all, I practice it. But ask yourself: if your hairstylist keeps giving you bad haircuts, do you keep going back? If a restaurant serves you a lousy meal, do you make another reservation? No, I’m sure you wouldn’t, and you shouldn’t stay in therapy that isn’t helping you, either.

Jonathan Alpert is a New York psychotherapist and the author of “Be Fearless: Change Your Life in 28 Days.”